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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS t I <br />/ 4 L <br />CITY/ZIP <br />CROSS STREET , 4 rMoi <br />AP 0 C J %� <br />PARCEL SIZE ) LAND USE APPLICATION # <br />�r' l f J� �l <br />OWNER NAME 4 <br />l <br />`r PHONED !` I <br />t /I —�i�� j <br />iD <br />OWNER ADDRESS `y �j�� e� j�1 pf,Qy <br />oviI ' <br />CITYISTATE/ZIP / (! J� <br />r <br />/� <br />//� �T <br />CONTRACTOR <br />PHONE( <br />"1/�1 ( 1 <br />' l l <br />CONTRACTOR ADDRESS t_ �` V 1 <br />/ <br />9/ 7IL��/�� <br />CfrY/STATE/ZIP ���' [` / / )� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />C.rryISTATE/ZIP <br />LICENSE C-57 <br />I C-61 ❑ D-09 <br />F Other <br />NUMBER/Ib I EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (439 1 ) Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED USE Domestic/Private C Irrigation/Agricultural Ii Industrial I_i Water Quality Monitoring Soil Sampling/Characterization <br />I Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK I_= New Well E Replacement Well E Well Alteration/Modification I-1 Other <br />[ Monitoring Well(s) # of wells E Soil Boring(s) # of borings I I Geotechnical # of borings <br />C Out -Of -Service ell C Out -Of -Service Well Renewal I I Cross -Connection Repair <br />I New Pump Pump Replacement I Pump Repair I I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method i Mud Rotary 1 Air Rotary [ I Auger f I Cable Tool I i Push Point I I Other <br />Proposed Well Depth ft Excavation in diameter I l Open Bottom r Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I I Steel I I Plastic I ? Stainless Steel _ Other <br />Grout Seal Depth ft L Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) E Other <br />Grout Placement Method LI Pumped i Free Fall L Other 1 Retardant I Accelerator (name) <br />PEDESTAL Installed By ❑ Driller E Pump Contractor I_I Other <br />L. Concrete Pedestal I]Dimensions: Width ft Length ft Thick <br />�in i Christy Box E Stove Pipe <br />PUMP A Submersible❑ Turbine L Other HP Pump Set / `f(-..' ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 2001 radius of proposed well. <br />1TINTFNI 'kl 24 TIOLRt ADN'AN('L NOTICE REQUIRED Fr)R INSPECTIONS - PLEASE CALL. (2091 051 -7t,9 - <br />DEPARTMENT USE ONLY <br />Application Accepted By �� Date <br />Grout Inspection By Date <br />Pump Inspection By % L Date t 3 ] <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area L1 C' �% Employee ID# F �� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received C9he- Amount Dat Permit/ Invoice # Well ID# <br />Codes Info B ash Remitted Service Request # <br />3Ki477 <br />enulws-nr,ions/mzl r« 1 t Wall /PurnrPumiit <br />N <br />m <br />D <br />0 <br />v <br />m <br />w <br />